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Welcome Applicants!! Morning Report: Friday, November 18th Eating Disorders A Little History Lesson… Behaviors simulating those seen in current eating disorders go back to: • Binging and purging seen in ancient Rome • Fasting and exercise reported among ascetics in the Middle Ages A Little History Lesson… The Island of Fiji had no people with eating disorders for 2 centuries until the appearance of American television programs! Demographics 0.5% of adolescent and young adult women have anorexia nervosa • Begins in adolescence 1-3% have bulimia nervosa • Begins young adulthood Much more common in women (10-20:1) • Recent increase seen in men Demographics Seen more commonly in Caucasian and Asian youth • Less in African American and Latino youth More common in developed than in developing countries Pathogenesis Multifactorial • Cultural factors • Individual and family factors • Genetic/ biochemical factors Cultural Factors Individual and Family Factors Individual Factors • Anorexia nervosa Lack of control and self-confidence found in otherwise successful, although somewhat restricted, young women • Bulimia nervosa Impulsivity Ongoing substance abuse ?Past sexual abuse Individual and Family Factors Family Factors • Over-involvement • Enmeshment Genetic/ Biological Factors Cultural, psychological and family factors likely not sufficient to cause the onset of an eating disorder Psychiatric conditions more common in individuals/ families with eating disorders • Depression • OCD • Addictions Genetic/ Biologic Factors Several alterations are being considered • Hormonal Ghrelin Leptin Melanocortin • Genetic Serotonin receptor genes Pathogenesis, Presentation and Prevention… *Diagnosis Diagnosis Eating Disorder, NOS • Those who have not missed 3 menstrual cycles or are not quite 15% below IBW • Those who vomit or use laxatives regularly but do not binge • Children 8-12 whose eating disorder behaviors are not driven by a fear of gaining weight Evaluation Nutrition History • Weight • Diet • Eating disorder behaviors Excessive exercise? Use of diet pills, laxatives, diuretics, ipecac • **Have parents confirm history** Evaluation Medical symptoms • Malnutrition Constipation Feeling cold/faint • Vomiting Chest pain Hematemesis • Other medical causes of wt loss HA Polyuria/ polydipsia Persistent Diarrhea Evaluation Psychosocial History • What is the individual thinking? • How is he/she functioning? • Body image? • Reason for wt loss? • Symptoms of depression or other psych diagnoses? Suicidality?? *Differential Diagnosis *Complications Medical complications • Malnutrition of anorexia nervosa • Bulimic behaviors • Refeeding syndrome *Complications Metabolic abnormalities • Electrolyte disturbances Anorexia: hyper/hyponatremia Bulimia (vomiting/ laxative use): hypochloremic, hypokalemic metabolic alkalosis • CAN RESULT IN SUDDEN DEATH!!! Rapid refeeding: hypophosphotemia *Complications Cardiac Abnormalities • Anorexia Bradycardia Hypotension Orthostasis Prolonged QT interval Pericardial effusion • Bulimia Sudden cardiac death due to hypokalemia Irreversible cardiomyopathy • Refeeding Cardiac failure *Complications Gastrointestinal abnormalities • Anorexia Abdominal pain Constipation Delayed gastric emptying with prolonged peristalsis • Bulimia Esophageal irritation • Chest pain • (GER symptoms) *Complications Endocrine abnormalities • Decreased LH/FSH Amenorrhea osteopenia osteoporosis • Decreased thyroid function Low temperature, pulse, BMR, ECG voltage T4/TSH in low-normal range; T3 may be low (“euthyroid sick syndrome”) • Decreased vasopressin Polyuria *Complications Neurologic abnormalities • Seizures • Peripheral neuropathy • Brain atrophy Hematological abnormalities • Mild anemia (?low WBC and plts) *Management Laboratory evaluation • CBC • BMP • UA • TFTs ?Other hormonal values • EKG *When to Admit? Mild cases • Outpatient management Pediatrician Nutritionist More severe cases • Outpatient management Eating disorder team • Inpatient management *Treatment Watch for and intervene with complications • Electrolyte abnormalities • Cardiac abnormalities • Refeeding syndrome • Amenorrhea • Osteopenia *Treatment Nutritional therapy • Anorexia Weight GAIN! • Diets in the range of 1000-2000 kcal range used initially with slow increases by 200-400 kcal to a goal of 2000-4000 kcal • Goal 1-1.25 lbs/wk or 4-5 lbs/mo • Daily food diary • Exercise restriction (if needed) • Bulimia Nutritional stabilization *Treatment Psychological Therapy • Counseling Individual (mainstay) Family Group (?) • Medications SSRIs • Affect amount of binging and purging in bulimia • Do not affect weight gain in anorexic patients (?decrease relapse) Atypical anti-psychotics *Prognosis ALL outcomes (short and long-term) are VARIABLE • No indicator provides a specific prognosis for any individual case ??Hospital discharge wt in pts with anorexia Long-term outcome • 50% of patients do well, 30% do reasonably well but have symptoms, 20% do poorly • Mortality 5-10% Highest mortality rates of all psychiatric illnesses *Prognosis Long-term outcome (con’t) • Prognosis in adolescents better?? Good motivation to maintain a high level of suspicion and have a low threshold to intervene! Thanks for your attention! Noon Conference: Dr. Simon, Sinusitis
